Fax Cover Sheet To: Health Plans of Georgia Fax #: 770-271-4012
Fax Cover Sheet To: Health Plans of Georgia Fax #: 770-271-4012 Please accept my completed application and contact me to confirm receipt. Name: ______________________________________________________ Email: _______________________________________________________ Phone: ______________________________________________________ Pre-Notice Information regarding your insurability will be treated as confidential. Humana or its reinsurers, may, however make a brief report thereon to Medical Information Bureau (MIB), a not-for-profit membership organization of insurance companies, which operates an information exchange on behalf of its Members. If you apply to another MIB Member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with information in its file. Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. Please contact MIB at 866-692-6901 (TTY 866-346-3642). If you question the accuracy of information in MIB’s file, you may contact MIB and seek correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of MIB’s information office is Post Office Box 105, Essex Station, Boston, Massachusetts 02112. Humana, or its reinsurers, may also release information in its file to other insurance companies to whom you apply for life or health insurance, or to whom a claim for benefits may be submitted. PDN:_ _________________________ (FOR INTERNAL USE ONLY) GN-71001 - Rev. 9/2010 HumanaOne Individual Insurance Application Please print clearly in ink. Complete all questions. Fill in all fields or indicate “not applicable.” Date of application: ___________________ Requested Effective Date: ___________________ This application is for: New Business (First time applicant) Reinstatement (Reapplication) Change/Modification to Existing Policy GEORGIA Reason for change __________________________________________ Change/Modification to Existing Policy #________________________ Coverage Options Health Coverage Optional Benefits Please complete this section when selecting a health plan. Plan name Deductible Office visit copay Please select an optional benefit if available with chosen health plan. Prescription drug deductible: $150 $300 $500 Supplemental Accident Benefit: $1,000 $2,500 Dental Coverage Dental Traditional Plus Dental Preventive Plus $5,000 $10,000 Carryover Deductible Mental Disorder Benefit Please note: You may purchase dental coverage if health coverage is chosen. If dental is selected, it will be approved if the health coverage is approved. If you are changing or modifying an existing/approved policy or plan, dental is only available at your anniversary. Life Coverage Please complete this section if choosing the term life plan for primary applicant and/or spouse. Please include an additional page if you need to list multiple beneficiaries. Each additional page must be signed and dated. Primary Applicant: Spouse: Term Life Plan (Minimum selection is $25,000. Maximum selection is $150,000. Additional amounts must be purchased in $25,000 increments.) Term Life Plan (Minimum selection is $25,000. Maximum selection is $150,000. Additional amounts must be purchased in $25,000 increments.) Term life insurance amount: $_____________ Term life insurance amount: $_____________ Term length: 10 years 15 years 20 years Term length: 10 years 15 years 20 years Primary beneficiary name Primary beneficiary name Relationship Benefit % Relationship Contingent beneficiary name Benefit % Contingent beneficiary name Relationship Benefit % Relationship Benefit % Primary Applicant Information If child-only coverage is requested, the youngest child is the Primary Applicant. Questions must be filled out by custodial parent or legal guardian. First name MI Last name Height Weight Gender Date of birth MF Home address (not P.O. Box) City Social Security # Type of business or industry Country or State of birth Occupation Mailing address (if different from home address) State ZIP code E-mail Home phone # Daytime phone # City State ZIP code Policyholder name if different than Primary Applicant (applicable for child-only application) Consumer Choice Option: If you are nominating a health care provider or specialist please complete the section below. Current Patient No Yes Name of health care provider or specialist GA-71002 12/2010 PDN: _________________________ (FOR INTERNAL USE ONLY) Page 1 - Rev. 12/2010 Parent or Guardian Information Please complete this section if Primary Applicant is under 18 years of age. First name MI Last name Home address (not P.O. Box) E-mail City Home phone # State Daytime phone # ZIP code Relationship to child(ren) Family Information Please complete only if your spouse and/or dependent children are applying for coverage. Attach an additional family information sheet if necessary. Each additional page must be signed and dated. Spouse First name MI Last name Height Weight Gender Date of birth MF Country or State of birth Spouse’s type of business or industry Social Security # Spouse’s occupation E-mail Dependent 1 First name MI Last name Height Weight Gender Date of birth MF Dependent 2 First name MI Last name Height Weight Gender Date of birth MF Dependent 3 First name MI Last name Height Weight Gender Date of birth MF Dependent 4 First name MI Last name Height Weight Gender Date of birth MF Existing/Prior Coverage IMPORTANT: DO NOT cancel any existing coverage until you receive written notification from Humana of your acceptance for coverage. • Existing or Prior Health Coverage If you are applying for health coverage, please provide the status of current coverage or coverage within the past 24 months, including Humana, for each applicant. If additional space is needed, please attach additional pages. Each additional page must be signed and dated. No Yes • Do you or anyone applying for coverage have any major medical health insurance coverage currently in force? If YES, please supply the following for all applicants applying for coverage on the policy: Name(s) of covered persons Major Medical Insurance Carrier Name • Effective Date If NO, please answer the following question: No Yes Have you or anyone applying for coverage had major medical health insurance coverage within the past 24 months? • If YES, please supply the following for all applicants applying for coverage on the policy: Name(s) of covered persons Major Medical Insurance Carrier Name Effective Date Termination Date GA-71002 12/2010 PDN: _________________________ (FOR INTERNAL USE ONLY) Page 2 - Rev. 12/2010 • Existing Dental Coverage 1. No Yes • Does anyone applying for coverage currently have or had any group or individual dental coverage within the last 18 months? If YES, please supply the following for all applicants applying for coverage on the policy: Name(s) Effective Date Insurance Carrier Name Termination Date Name(s) Effective Date Insurance Carrier Name Termination Date 2. No Yes Will the insurance coverage applied for be used to replace existing dental coverage? • Existing Life Coverage Primary Applicant: 1. No Yes Do you have any life insurance and/or annuity coverage currently in force? 2. No Yes Will the insurance coverage applied for be used to replace any existing life and/or annuity coverage? • If YES, please supply the following information: Company name Amount $ Policy # Spouse: 1. No Yes Do you have any life insurance and/or annuity coverage currently in force? 2. No Yes Will the insurance coverage applied for be used to replace any existing life and/or annuity coverage? • If YES, please supply the following information: Company name Amount $ Policy # Eligibility & Health Status Please answer for all individuals applying for coverage. Quoted premiums are only an estimate. We may need to adjust your premium based on underwriting. If the difference is less than 20 percent, we’ll adjust your premium automatically. If the difference is more than 20 percent, we’ll contact you. For this insurance to be issued, the following eligibility and health questions must be answered fully and truthfully. All requested health information including routine physical exams and information related to spouse and dependents applying for coverage must be provided. If any of the answers are “yes”, please provide complete details. Failure to fully disclose any eligibility or health information may cause your claim to be reduced or denied, including the applicability of a condition specific deductible; or may result in your policy being rescinded or modified back to your original effective date. 1. No Yes Is anyone applying for coverage a citizen of a country other than the United States? • If YES: Name(s): Has anyone applying for coverage: 2. No Yes 3. Experienced weight gain or loss of more than 20 pounds in the past 12 months? Within the past 12 months, has the primary applicant, or spouse or dependent applying for coverage used any tobacco product? Primary Applicant: No Yes Spouse: Dependent: No Yes No Yes 4. No Yes Has anyone applying for coverage participated in any dangerous or extreme sport activity in the past 24 months or plan to participate in the next year? 5. No Yes Are you or is any immediate family member (whether applying for coverage or not) pregnant, an expectant parent, in the process of adopting a child, or undergoing infertility treatment? Within the past 5 years, has anyone applying for coverage: 6. No Yes Been denied for health or life insurance or had their health coverage ridered, rated or rescinded? 7. No Yes Been diagnosed with or received treatment for Acquired Immune Deficiency Syndrome (AIDS), or tested positive for AIDS or Human Immunodeficiency Virus (HIV)? 8. No Yes Had any signs or symptoms of, been diagnosed with, sought counsel for or treated for any alcohol abuse, dependency or problem, or had any alcohol related arrests? 9. No Yes Used any illegal or taken prescription drugs not prescribed by their health care provider or had any signs or symptoms of, been diagnosed with, sought counsel for or treated for any drug abuse, dependency or problem; or had any drug related arrests? 10. No Yes Had any testing or procedure performed that has been abnormal or the results of which are pending or unknown? 11. No Yes Had surgery or been advised to have surgery that has not been completed? 12. No Yes Consulted, advised or recommended to have follow-up testing or treatment by a health care provider or specialist that has not been completed? GA-71002 12/2010 PDN: _________________________ (FOR INTERNAL USE ONLY) Page 3 - Rev. 12/2010 Eligibility & Health Status continued 13. Within the past 5 years, has anyone applying for coverage had signs of, been prescribed medication or received injections for, or been diagnosed with or treated for: A. No Yes Chest pain or Heart Attack M. No Yes B. No Yes No Yes No Yes High Blood Pressure or Hypertension N. High Cholesterol or Triglycerides O. Cancer or Tumor of any kind P. No Yes No Yes No Yes Diabetes or High Blood Sugar Q. Stroke R. Paralysis S. Epilepsy or Seizure T. C. D. No Yes F. No Yes G. No Yes H. No Yes I. No Yes J. No Yes E. K. L. No Yes No Yes Migraines or frequent or severe headaches U. Hepatitis V. Sleep Apnea W. Anxiety or Depression X. No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes ADD/ADHD (Attention Deficit Disorder) or any other Behavioral, Emotional, Mental or Nervous Disorders Eating Disorder Developmental Disorder or Delay Human Papilloma Virus or Sexually Transmitted Disease Infertility Uterine Fibroids Cyst, Growth, Lump or Polyp Hernia Arthritis Implants, Pins, Plates, Rods, Screws or Prosthesis Connective Tissue or Autoimmune Disorder Birth Defect 14. Within the past 5 years, has anyone applying for coverage been prescribed medication or received injections for, been treated for or had signs or symptoms of any injury, condition, disease or disorder involving or affecting: A. B. C. D. E. F. No Yes No Yes No Yes No Yes No Yes No Yes Gallbladder, Liver or Pancreas G. Colon, Esophagus or Stomach H. Bladder or Kidneys I. Back, Disc, Neck or Spine J. Knee, Hip or Shoulder K. Lungs L. No Yes No Yes No Yes No Yes No Yes No Yes Eyes, Ears, Nose, Throat or Sinuses Breasts Menstrual Cycle Cervix, Ovaries, Uterus or Vagina Penis, Prostate or Testicles Skin 15. Within the past 5 years, has anyone applying for coverage been prescribed medication or received injections for, been treated for or had signs or symptoms of any injury, condition, disease or disorder (not previously disclosed) involving or affecting: A. B. C. D. No Yes No Yes No Yes No Yes Blood Vessels, Heart or Circulatory System E. Blood, Gland, Pituitary, Thyroid or Lymph System Brain or Nervous System F. Digestive System H. G. No Yes No Yes No Yes No Yes Urinary System Musculoskeletal System, including Bone/Joint Disorders Respiratory System Reproductive System 16. No Yes Within the past 24 months, has anyone applying for coverage seen a health care provider or specialist for a routine physical/wellness exam, or been seen for any reason not previously disclosed? 17. No Yes Within the past 24 months, has anyone applying for coverage been advised to take or taken any prescription medications or injections not previously disclosed? Additional Eligibility or Health Status Question Information To be completed if anyone applying for coverage answered “Yes” to any question(s) in the Eligibility & Health Status section. Please provide details such as; specific condition, dates of treatment, results or advice given, medication (dosage and frequency), treatment plan, recovery date, physician name and address. Attach an additional health information sheet if necessary. Additional information sheets must be signed and dated by the primary applicant or legal representative and/or spouse (if applying). Question # Letter Person treated Condition Letter Person treated Condition Letter Person treated Condition Details: Question # Details: Question # Details: GA-71002 12/2010 PDN: _________________________ (FOR INTERNAL USE ONLY) Page 4 - Rev. 12/2010 Agreement and Signature True and Complete Acknowledgment: I understand, agree and represent: I have read this document or it has been read to me. The answers are true and complete. I agree to immediately notify Humana of any changes to the information contained in this form that occur prior to the policy effective date. I have received and reviewed any state or federal required disclosures. I acknowledge that neither I nor the agent have the right to waive or incompletely answer any question, determine coverage or insurability, alter any contract, or waive any of Humana’s other rights and requirements. This policy applied for is not an employer-sponsored group health plan and it does not comply with state or federal small employer laws. I certify that I will not use pre-tax income to pay premiums associated with this policy or otherwise receive favorable tax treatment under federal or state law that will be used to pay insurance premiums. If this application for coverage is accepted, coverage will be effective on the date specified by Humana on the policy. Unless Humana agrees to an earlier date, the effective date for sickness begins on the 15th day after the approved effective date of the policy. Acceptance of premium and fees does not guarantee coverage. Any misrepresentation on this application may be used by Humana during the first two policy years to void the contract or modify the terms of coverage. This may result in loss of coverage, modification of coverage and/or claim denial. I agree to terminate any existing coverage if this application is approved and coverage accepted. As a parent or legal guardian of a dependent 18 years or older applying for coverage, I attest by my signature below, that I have gathered the necessary health information regarding my dependent in order to fully and truthfully complete this application. This document, together with any supplements, will form part of and be the basis for any policy issued. Any person who knowingly presents false information in an application for insurance or life settlement contract is guilty of a crime and, upon conviction, may be subject to fines or confinement in prison, or both. If you decide not to sign this agreement, we will decline to enroll you in a medical plan or to give you medical benefits. Primary Applicant or Legal Guardian Signature _________________________________________________ Relationship of Legal Guardian _______________________________________________________________ Spouse Signature (if covered dependent) ______________________________________________________ Date ____________________ Date ____________________ Agent / Producer Information This section to be completed by Agent or Producer. Agent / Agency of Record: (for commissions and correspondence) Writing Agent / Producer: Name (print) Steven McClelland Name (print) Humana Agent # 1001727 Humana Agent # As the Writing Agent / Producer, I acknowledge that I am responsible to meet with the primary applicant submitting this application in order to fully and accurately represent the terms and conditions of the plans and services of the offering or insuring entity, or one of its subsidiaries. These provisions are available to me and the primary applicant in the benefit summary document or other plan literature. Writing Agent’s Signature _______________________________________________________________________ Date ____________________ The original version of this Agreement is in the English language. If there are any discrepancies or conflicts between the English and any other version that has been translated into another language, the English version will control. The offering Company(ies) listed below, severally or collectively, as the content may require, are referred to in this application as “Humana.” PPO plans insured by Humana Insurance Company POS plans offered by Humana Employers Health Plan of Georgia, Inc. and insured by Humana Insurance Company Life products insured by Humana Insurance Company Dental products insured by HumanaDental Insurance Company GA-71002 12/2010 PDN: _________________________ (FOR INTERNAL USE ONLY) Page 5 - Rev. 12/2010 HumanaOne Dental Application Requested Effective Date: __ __/__ __/__ __ __ __ This form is for: q New Business (First time applicant) q Reinstatement (Reapplication) q Change/modification to Existing Policy or Plan GEORGIA Reason for change_________________________________ Change/Modification to Existing Policy or Plan # __________________ 1. Coverage Please complete this section when selecting a dental product. Dental Coverage Product Name 2. Primary Applicant Information First name Home address (not P.O. Box) E-mail Social Security # MI Last name City Home phone # ( / / Gender q M q F Date of birth State ZIP code ) Daytime phone # ( ) 3. Family Information Please complete only if your spouse and/or dependent children are applying for coverage. Attach an additional family information sheet if necessary. Each additional page must be signed and dated. Spouse First name MI Last name / / Gender q M q F Date of birth Social Security # E-mail Dependent First name Social Security # MI Last name E-mail Gender q M q F Date of birth / / Dependent First name Social Security # MI Last name E-mail Gender q M q F Date of birth / / Dependent First name Social Security # MI Last name E-mail Gender q M q F Date of birth / / 4. Agent / Producer Information This section to be completed by Agent or Producer. 1. Agent / Agency of Record: (for commissions and correspondence) 2. Writing Agent / Producer: Name (print) Steven McClelland Name (print) Humana Agent # 1001727 Humana Agent # As the Writing Agent / Producer, I acknowledge that I am responsible to meet with the primary applicant submitting this application in order to fully and accurately represent the terms and conditions of the product and services of the offering or insuring entity, or one of its subsidiaries. These provisions are available to me and the primary applicant in the benefit summary document or other product literature. Writing agent’s signature_ _______________________________________________________________ Date __ __/__ __/__ __ __ __ 5. Agreement and Signature True and Complete Acknowledgment: I understand, agree and represent: I have read this document or it has been read to me. The answers are true and complete. I have received and reviewed any state or federal required disclosures. Neither I nor any agent or producer has the authority to waive a complete answer to any question, determine coverage or insurability, alter any contract, or waive any of Humana’s other rights and requirements. This product applied for is not an employer-sponsored group insurance policy and it does not comply with state or federal small employer laws. I certify that I do not qualify for or have willingly waived a group insurance policy or receive favorable tax treatment under federal or state law that will be used to pay insurance premiums. If this application for coverage is accepted, coverage will be effective on the date specified by Humana on the policy. Acceptance of premium and fees does not guarantee coverage. I agree to automatic withdrawal from my specified bank account or credit card for premium payment and administrative fees if selected on the HumanaOne Payment & Billing Authorization form. Any misrepresentation on this application may be used by Humana during the first two policy years to void the contract or modify the terms of coverage. This may result in loss of coverage, modification of coverage and/or claim denial. As a parent or legal guardian of a dependent 18 years or older applying for coverage, I attest by my signature below, that I have gathered the necessary insurance information from my dependent in order to fully and truthfully complete this application. This document, together with any supplements, will form part of and be the basis for any policy issued. Any person who submits an application containing a false, incomplete or deceptive statement may be guilty of insurance fraud. If you decide not to sign this agreement, we will decline to enroll you in an insurance product or to give you insurance benefits. Primary Insured or Legal Guardian Signature_ ________________________________________________ Date __ __/__ __/__ __ __ __ Relationship of Legal Guardian___________________________________________________________ Spouse Signature (if covered dependent)____________________________________________________ Date __ __/__ __/__ __ __ __ The offering Company(ies) listed below, severally or collectively, as the content may require, are referred to in this application as “Humana”. Dental products insured by HumanaDental Insurance Company GA-72002 3/2009 PDN:________________________ (FOR INTERNAL USE ONLY) Page 1 Rev. 6/2010 Payment Authorization & Association Enrollment Amount for each subsequent payment (based on the payment option selected) $_________________ (includes Association, Administration, and/or Billing fees if applicable) See initial payment section for initial payment amount. Primary Insured/Applicant Information Primary Insured/Applicant First name MI Last name Payer Information First name MI Last name Suffix Billing address City State Primary phone # Secondary phone # ZIP code 1. INITIAL Payment Options (not all payment options are available for all products or plans, see page 2 for details) Please choose either credit/debit card or one-time bank withdrawal of the initial payment. Initial payment for each product applied for or enrolled in will be drafted/charged separately against your account. A. ONE-TIME AUTOMATIC BANK WITHDRAWAL Bank name Account holder’s name Routing # Account # I authorize Humana to draw the initial payment of $___________ from the designated account. (includes enrollment, dues, and fees, if applicable) B. ONE-TIME CREDIT/DEBIT CARD PAYMENT Choose one: Visa Mastercard Card # Expiration Date / Cardholder’s name I authorize Humana to charge the initial payment of $___________ from the designated account. (includes enrollment, dues, and fees, if applicable) 2. SUBSEQUENT Payment Options (not all payment options are available for all products or plans, see page 2 for details) Please select payment option for your billing cycle and payment preference for your premium payment. Payment of premiums for each product applied for or enrolled in will be drafted/charged separately against your account. A. RECURRING AUTOMATIC BANK WITHDRAWAL Choose one: Monthly Payment Semi-annual Payment Choose one: Savings Checking Annual Payment Bank name Account holder’s name Routing # Account # I authorize Humana to draw subsequent payment of $___________ from the designated account until this authorization is revoked. (includes dues and fees, if applicable) B. CREDIT/DEBIT CARD Choose one: Visa Mastercard If selected, a Billing fee of $_____________ will apply. Choose one: Monthly Payment Semi-annual Payment Annual Payment Card # Expiration Date / Cardholder’s name I authorize Humana to charge the subsequent payment of $___________ from the designated account until this authorization is revoked. (includes dues and fees, if applicable) C. PAPER BILL See page 2 for details. Monthly Payment Quarterly Payment Semi-annual Payment Choose one: If selected, an Administration/Billing fee of $___________will apply. GN-71123 NF PDN: ______________________ (FOR INTERNAL USE ONLY) Rev. 1/2013 Page 1 Agreement & Signature All Products and Plans - Rates quoted are not guaranteed. The final rate will be based on underwriting completion (if applicable) and approval of the application or enrollment form. Additional charges may apply based on method of payment chosen. Medical - Debit information, refer to the Payment Option Information section below. Dental and Vision - Debit information, refer to the Payment Option Information section below. I understand this is a minimum one-year contract that auto-renews and is non-refundable and non-cancellable for all insureds (excluding Maryland). Life and Supplemental - Debit on the _____ day of the month (1-28 only; 29, 30, 31 not available). If no election is made, debits will be made on the day of Policy. Each debit shall constitute proper notice of premium due and will be made on the day selected above or, if no day is selected, the day of Policy. This Authorization shall not become effective unless and until the coverage is issued. This Authorization shall not be construed as modifying any provisions of the coverage. Humana shall not incur any liability if a draft is returned unpaid by the bank. Drafts which do not clear within the time stipulated in the Policy for payment of premium shall constitute nonpayment of premiums and coverage shall lapse subject to nonforfeiture provisions. This Authorization may be discontinued by Humana or by the Authorized Account Holder at any time within FIVE (5) business days prior to the debit date. Upon termination of this Authorization, the premiums on the Policy covered will be payable annually. Humana will notify me TEN (10) days prior to any changes in payment amounts. By my signature, I acknowledge that I am an authorized user of the account information provided. Signature of Primary Insured/Applicant or Legal Guardian ________________________________________________________________________________________ Date ______________________ Association Enrollment The Association, Peoples’ Benefit Alliance, is a membership organization that provides educational information and discounts on goods and services to its members. Membership in the Association is required, at additional cost, in order to be eligible for insurance coverage. The Association benefits information will be sent under separate cover. By signing below, you are requesting enrollment in the Association. Primary Association Member or Legal Guardian Signature ________________________________________________________________________________________ Date ______________________ Payment Option Information Medical and Traditional Dental Dental and Vision Life and Supplemental • Initial payment, Mastercard or Visa • Monthly payments,Mastercard only • Quarterly and Semi-Annual payments for Paper Bill option only • Intial payment debited the later of the Certificate effective date or the Policy issue date • Subsequent payment debited the 1st business day of each month • Traditional Dental: debited the 1st business day of each month (excluding Traditional Dental) • Mastercard or Visa • No Semi-Annual payment option • Debited the 15th of each month (one month in advance) • Mastercard or Visa • No Paper Bill on Initial payment • Junior Estate Builder options: Initial and Annual payments (automatic bank withdrawal and recurring automatic bank withdrawal only) Billing and Association Fee Information Medical and Traditional Dental Dental and Vision • Billing Fee (excluding Traditional Dental) - $10.00/mo., not applicable in GA, KS, MI, MO, NC • Administration Fee $5.00/mo. in CO, UT and $6.00/mo. in MS - $1.00 per month for Monthly payments - waived for Recurring Automatic - waived for Annual payments Bank Withdrawal • Enrollment Fee • Paper Bill Fee $35.00 one-time fee (non-refundable) - Paper Bill $10.00/mo. (not applicable in KS, MI) $5.00/mo. in CO, UT and $6.00/mo. in MS Medical Association enrollment is necessary to be eligible for medical products in AL, AZ, FL (excluding FL HMO products), IL, MI, WI • Association Dues - $3.95/mo. (non-refundable) Life and Supplemental • Billing Fee $1.00 Monthly, $6.00 Semi-Annually, $12.00 Annually - not applicable in CA, GA, IN, KS, MA, MD, MI, NC, NJ, WA - waived for Recurring Automatic Bank Withdrawal and/or check payments Dental and Vision Association enrollment is necessary to be eligible for HumanaOne Dental and Vision Products except in the states of CO, GA, MD, MN, NH, NY, SD and UT. The Dental Value Plan C550, Dental Value Plan HI215, Dental Traditional and Discount products do not require Association enrollment. • Association Dues - Veteran’s Dental: 50¢/mo. - All other plans 75¢/mo. each product (non-refundable) The companies listed below, severally or collectively, as the context may require, are referred to in this Authorization as Humana. Humana Insurance Company, Humana Health Plan, Inc., Humana Health Insurance Company of Florida, Inc., Humana Health Benefit Plan of Louisiana, Inc., HumanaDental Insurance Company, The Dental Concern, Inc., Humana Insurance Company of Kentucky, Humana Employers Health Plan of Georgia, Inc., Humana Medical Plan, Inc., Kanawha Insurance Company, Humana Insurance Company of New York, CompBenefits Insurance Company, CompBenefits Company (a Pre-paid Limited Health Service Organization and licensed under Chapter 636, Florida Statutes), CompBenefits Dental, Inc., CompBenefits of Alabama, Inc., CompBenefits of Georgia, Inc., American Dental Plan of North Carolina, Inc., and DentiCare, Inc. (d/b/a CompBenefits) GN-71123 NF PDN: ______________________ (FOR INTERNAL USE ONLY) Rev. 1/2013 Page 2 Medical Records Release Authorization Purpose of the Authorization By signing the form, you will authorize the disclosure and use of the protected health information described below for pre-enrollment underwriting or risk-rating of health insurance coverage for you, or to determine your eligibility for enrollment or benefits under a health plan. Information we will use and/or disclose My dependents and I authorize any physician, medical or health care practitioner, hospital, clinic, veterans administration facility, other medical or medically related facility, third party administrator, Pharmacy Benefit Manager, insurance, HMO or reinsuring company, the Medical Information Bureau, Inc., employer or the Consumer Reporting Agency having information regarding myself and my dependents, including information concerning, advice, diagnosis, treatment and care of the physical, psychiatric, mental or emotional conditions, drug, substance or alcohol abuse, illness and copies of all hospital or medical records, non-public personal health information, and any other nonmedical information to share any and all such information with the Company, its reinsurer or its legal representatives, and its affiliates. • The information obtained by use of this authorization may be used by the Company to determine eligibility for coverage, eligibility for benefits under an existing policy, plan administration, and make claim determinations. • Any information obtained will not be released by the Company to any person or organization except to reinsuring companies, the Medical Information Bureau, Inc., or other persons or organizations performing health care operations or business or legal services in connection with any application, claim or as may be otherwise lawfully required, or as we may further authorize. If a Consumer Reporting Agency is used, I (we) may request to be interviewed in connection with the preparation of the report and I (we) may request a copy of the report. • Once personal and health (including medical, dental and pharmacy) information is disclosed pursuant to this authorization, it may be redisclosed by the recipient and the information may not be protected by federal and state privacy requirements. Expiration and revocation • A copy of this authorization is available to me or my legal representative upon written request. A photographic copy of this authorization shall be as valid as the original. • This authorization shall be valid for two years from the date shown below. I have the right to revoke this authorization at any time. To revoke this authorization: • I must do so in writing and send my written revocation to Humana’s Privacy Office. • The revocation will not apply to information that has already been released in response to this authorization. • The revocation may adversely affect my application, a claim or a pending insurance action. • The revocation will become effective after it is received by Humana’s Privacy Office. If you decide not to sign this authorization, we will decline to enroll you in a medical plan or to give you medical benefits. Primary Applicant or Legal Guardian Signature______________________________________________________ Date __ __/__ __/__ __ __ __ Relationship of Legal Guardian_ __________________________________________________________________ Spouse Signature _____________________________________________________________________________ Date __ __/__ __/__ __ __ __ (if covered dependent) Child Signature _____________________________________________________________________________ Date __ __/__ __/__ __ __ __ (if covered dependent over the legal age) The offering Company(ies) listed below, severally or collectively, as the content may require, are referred to in this application as “Humana.” Medical and Life products insured by Humana Insurance Company POS plans offered by Humana Employers Health Plan of Georgia, Inc. , and/or insured by Humana Insurance Company PPO plans insured by Humana Insurance Company Dental products insured by HumanaDental Insurance Company GA-71003 12/2007 PDN:__________________________ (FOR INTERNAL USE ONLY) Rev. 9/2008
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